Billing Bulletin - eHealth Saskatchewan

Billing Bulletin
      Billing Bulletin No. 7
      Published by Medical Services Branch at 306-787-3454
      October 1, 2021

IMPORTANT HEALTH WEBSITE LINKS
All Medical Services Branch Payment Schedules, Newsletters, Operations Bulletins, Billing
Bulletins, Billing Information Sheets and forms are available at:
https://www.ehealthsask.ca/services/resources/establish-operate-practice/Pages/Physicians.aspx

CONTACT INFORMATION
Physician Billing Inquiries                    Claims Processing Support Inquiries
Direct all physician billing inquiries to:     Direct all claims submission & processing inquiries to:
Phone: 306-787-3454                            Phone: 306-787-0182 or 306-787-3470
Fax: 306-798-0582                              Fax: 306-798-0582

 Physician Audit Inquiries                     Physician Billing Education Inquiries
 Direct all physician audit and professional   Direct all physician education and online billing
rreview inquiries to:                          course inquiries to:
 Policy, Governance and Audit Unit             Insured Services Officer
 Phone: 306-787-0496                           Phone: 306-787-9011
 Fax: 306-787-3761
 Email: MSBPaymentsandAudit@health.gov.sk.ca

BILLING RESOURCES & BILLING INFORMATION SHEETS
There are important billing resources available on the eHealth website. These documents are
provided to all new physicians upon registering with Medical Services Branch (MSB). They are
also available for download or viewing at the above link. Physicians should ensure that they
avail themselves of this important information.

ehealthsask.ca

October 1, 2021                                                                 Billing Bulletin

FREE ONLINE BILLING COURSE:
MSB offers an online billing course that outlines the process involved in the billing cycle. The
course is appropriate for beginners, as well as those with more advanced billing knowledge and
is designed to be flexible. Start and stop at your leisure! Your progress will be saved for you to
resume when convenient as, depending on the participant's knowledge, the course could take
between hours or days to complete.

HOW TO GET STARTED:
     1. Go to the following link: https://msbonlinebillingcourse.litmos.com/self-signup/
     2. Enter the required information and use the following code: OLBC
     3. You will need to complete a basic User Profile upon signup, requiring only an email
        address for your User Name and a valid password, consisting of the following
        criteria:

             •     Minimum of 8 characters
             •     1 upper case
             •     1 lower case
             •     1 number
             •     1 special character

To start the course, you will be presented with a list of the modules under the course, along
with a button to “Start the Learning Path”. You can choose to start at the top and work to the
bottom or click on any module in the sequence. Alternatively, you can exit the module you are
working on at any time (using the orange ‘exit’ button in the right corner) and come back later
or you can move onto another module of your choice.

You will require a current Physicians Payment Schedule to facilitate you in the course, which
can be found at this link: https://www.ehealthsask.ca/services/resources/establish-operate-
practice/Pages/Physicians.aspx

Once you have completed the signup process, use the following link to re-enter the site with
your new credentials: https://msbonlinebillingcourse.litmos.com

If you have any questions regarding the Online Billing Course, please contact 306-787-9011.

October 1, 2021                                                                          Billing Bulletin

STATUTORY HOLIDAYS FOR THE PURPOSES OF BILLING TIME-OF-DAY
PREMIUMS AND/OR SPECIAL CALL/SURCHARGES:
Please be advised that statutory holidays for the purposes of billing any type of time-of-day
premium or special call/surcharge are according to the Government’s observed/designated
holidays listed below, and may be different than the Saskatchewan Health Authority
designated holidays.

     HOLIDAY                       ACTUAL DATE                        OBSERVED/BILLED ON
     Thanksgiving Day              Monday October 11, 2021            Monday October 11, 2021

     Remembrance Day               Thursday November 11, 2021         Thursday November 11, 2021

     Christmas Day                 Saturday December 25, 2021         Friday December 24, 2021

     Boxing Day                    Sunday December 26, 2021           Monday December 27, 2021

     New Year’s Day                Saturday January 1, 2022           Monday January 3, 2022

     Family Day                    Monday February 21, 2022           Monday February 21, 2022

     Good Friday*                  Friday April 15, 2022              Friday April 15, 2022

       * Please note that there is no designated government holiday on Easter Monday for the purposes of
       billing.

 AUDIT

JOINT MEDICAL PROFESSIONAL REVIEW COMMITTEE (JMPRC)
The JMPRC is a legislated, physician peer-review committee with two (2) physicians appointed
by each of the Saskatchewan Medical Association, the College of Physicians and Surgeons of
Saskatchewan and the Ministry of Health.

The JMPRC is responsible for reviewing a physician’s pattern of medical practice related to
billing. It has the authority to review a physician’s billings over a 15-month period, request
copies of medical records, and interview physicians with respect to their pattern of medical
practice. If a physician’s pattern of medical practice is deemed to be unacceptable by the
JMPRC, the JMPRC has the legislative authority to order a physician to repay monies to the
government.

What is a pattern of medical practice as it relates to billing?
Practice management remains a key component to health care delivery, including the judicious
use of public funds when determining what services are medically required and billable. In a
taxpayer-funded system, the decision to provide a service should be based on whether it is

October 1, 2021                                                                    Billing Bulletin

medically required—a professional judgment that should be informed by medical research
studies and best practice guidelines. The following factors that can impact a physician’s pattern
of practice as it relates to billing can include:

   • The manner in which a physician manages his overall practice such as scheduling
     appropriate follow-up visits based on standard clinical guidelines and pathways;
   • The manner in which a physician manages chronic and controlled medication refills;
   • The manner in which a physician manages acute and chronic diseases;
   • The manner in which a physician manages patient access to the clinic;
   • The manner in which a physician manages patients presenting with multiple ailments
     and/or only allowing one issue per encounter;
   • The manner in which a physician orders diagnostic and laboratory testing;
   • The manner in which a physician documents his medical records.

Inadequate or inappropriate practice management should not result in non-medically
required and inappropriate billings being submitted to the publicly funded system. Overuse
and misuse of public funds can significantly impact on patients and the health care system.
As evidenced through the reassessments ordered by the JMPRC, it suggests that the costs are
considerable.

The following is a summary of monies ordered to be repaid by physicians due to inappropriate
billings in the last 3 fiscal years (April 1 to March 31):

     Fiscal Year   Amount Ordered to be Recovered   No. of physicians   Average Recovery per Physician
      2018-19               $1,598,881                     7                      $228,412
      2019-20               $1,783,770                     8                      $222,971
      2020-21               $2,035,232                     7                      $290,747

To learn more about the JMPRC, you can access the billing information sheet here:

JMPRC Billing Information Sheet

BILLING AUDITS AND INVESTIGATIONS
Medical Services Branch has a legislative obligation to protect tax-payer funded services and
ensure that the use of these funds is appropriate and aligns with existing legislation.
Minimizing loss and ensuring government accountability to a publicly funded system are key.

October 1, 2021                                                                  Billing Bulletin

The use of routine audits are an effective method used to deter and identify the potential
misuse and overuse of public funds. Eliminating and deterring inappropriate billings that have
minimal evidence of a benefit or cost-effectiveness can reduce potential harm to patients and
excessive costs to the publicly funded system. This, in turn, leaves more money available to
potentially address unmet health care needs and to ensure the best possible distribution of
public resources.

Billing audits and investigations can be initiated in a wide variety of ways. MSB undertakes
routine audits on a regular basis, but investigations can also be initiated through inquiries and
complaints from the public.

If physicians or other members of the public have potential concerns about a physician’s
billing practices, they are encouraged to contact Policy, Governance and Audit at:

MSBPaymentsAndAudit@health.gov.sk.ca

To learn more about physician audits, you can access the information sheets here:

Routine Audit Billing Information Sheet
Payment Integrity (Audit) Billing Information Sheet

INAPPROPRIATE BILLING AND UNPROFESSIONAL CONDUCT
Because Medicare has a huge impact on the lives of all Saskatchewan residents and represents
one of governments highest cost programs, it is important that physicians understand the
important role they play in not only providing quality care to their patients, but also in ensuring
they understand their professional, legal and ethical obligations to submit billings in an honest
and forthright manner.

When a physician signs a direct payment agreement with the government for the provision of
receiving direct payment for the medical services they provide, it is important that they are
ethical and judicious in their billing practices. Physicians have an obligation to ensure that the
billings they submit for payment are appropriate and align with legislation. Physicians should
be aware that any inappropriate billing issues identified through MSB audits and patient
verifications may be referred to the College of Physicians and Surgeons of Saskatchewan for
further investigation and that physicians may be investigated and/or disciplined under The
Medical Profession Act, 1981 (section (46)).

Physicians are strongly encouraged to avail themselves of all applicable resources and
education associated with billing. We appreciate your ongoing efforts in ensuring that the
services you submit for payment are accurate and align with legislation.

October 1, 2021                                                                    Billing Bulletin

 GENERAL

PHYSICIANS BILLING MEDICAL SERVICES ON THEMSELVES AND FAMILY
MEMBERS
Please ensure that you are aware of your billing obligations with respect to these
circumstances. Per the College of Physicians and Surgeons of Saskatchewan’s Bylaws (7.1) and
Code of Ethics item (7), physicians must:

     Limit treatment of yourself, your immediate family, or anyone with whom you have a
     similarly close relationship to minor or emergency interventions and only when another
     physician is not readily available; there should be no fee for such treatment.

Medical Services Branch routinely reviews services billed by physicians on family members (as
registered in the same family unit by Health Registries) or themselves. These services are
rejected under explanatory code “CG” in the Physician Payment Schedule. In certain
circumstances, as deemed necessary by MSB officials, this information is forwarded to the
College of Physicians and Surgeons for further investigation.

WORKERS’ COMPENSATION BOARD CLAIMS – BEST PRACTICE
Claims previously rejected under explanatory code “CW” that are not the responsibility of
Workers' Compensation Board (WCB), please resubmit the claim with a comment “Not WCB”
followed by the date submitted to and rejected by WCB.

For example: “Not WCB Jan 1/18 - Jan 31/18”.

VIRTUAL CARE CODES NOT ELIGIBLE FOR RECIPROCAL BILLING
Virtual Care and Pandemic services are not payable for non-residents of Saskatchewan or to
non-Saskatchewan physicians. Services must be billed directly to the non-resident who can
then submit to their provincial plan.

ICS WEBSITE – DID YOU KNOW?
The ICS site is available, regardless of vendor, for any client with a billing certificate. The ICS
site contains several resources available for your use, including Referring Doctor File and Run
Schedule. Another important item is the Validation Report, which can verify (in real time)
whether or not the Ministry received your submission.

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The online billing course contains an overview of the entire claims process, including details
regarding Certificates, the contents of the ICS site and other very helpful items. Please see
page 2 of this Billing Bulletin for more information regarding the online billing course.

UPDATED RESOURCES: HEALTH COVERAGE OUTSIDE OF SASKATCHEWAN
The following eHealth webpage has been updated to include resources for both physicians and
patients containing concise and printable Information Sheets. It is important to review this
information prior to a referral for care outside of Saskatchewan is initiated.

https://www.ehealthsask.ca/services/resources/Pages/Health-Coverage.aspx

Please be advised this same information can be found on pages 9 and 10 of the current
Physician Payment Schedule – which includes specific details regarding when a prior approval
request must be submitted for coverage consideration to:

            Director, Insured Services
            Medical Services Branch, Ministry of Health
            3475 Albert Street
            Regina, Canada S4S 6X6
            Phone: 306-798-0013 / Fax: 306-798-1124
            Email: caseworkunitmsb@health.gov.sk.ca

BILLING BILATERAL PROCEDURES
Some procedures may be performed bilaterally by the same doctor on the same day.

In circumstances where service codes are not billable with multiple “units”, such as ‘biometry
for measuring axial length’ (16W), bilateral services should be billed on separate lines with a
comment in the comment section of your claim stating ‘Left’ or ‘Right’, etc; otherwise, the
second service may be rejected as a duplicate under explanatory code ‘BA’.

In circumstances where service codes are billable with multiple “units”, bilateral services
should be billed on the same line with “2” units, such as bilateral wrist x-rays (165X). The
Physician Payment Schedule typically states when a service code is billable with multiple
“units” on a single claim line, using the phrase ‘bill units’, ‘add’ or ‘each additional’. If a claim is
received with the maximum number of lines (7) and the service code has been billed with
multiple units when not eligible, MSB cannot split the claim to allow processing. The claim will
then be returned to the physician for correction, which increases processing time and delays
payment.

October 1, 2021                                                                    Billing Bulletin

HOSPITAL CARE – BEST PRACTICES
When billing hospital care days, you do not need to wait for the patient to be discharged from
the hospital prior to submitting claims for payment. A billing ‘best practice’ is to bill at the end
of each 30 day period, this avoids any potential time limit issues.

    Per The Saskatchewan Medical Care Insurance Act, accounts for insured services must be
    received by the Ministry of Health within six months following the date of service to be
    eligible for payment.

When billing hospital days, it is helpful to indicate the admission and discharge dates in the
comment line. This will assist us to ensure that the spans are calculated accurately at the
correct rate.

 SECTION A – GENERAL SERVICES

615A/915A – HOUSE CALL SURCHARGES
The intent of payment under surcharge codes 615A and 915A is for a visit to a patient’s home
(not special care or nursing homes), where the visit is not initiated by the patient, but where
the physician judges that a visit is required, e.g. a follow-up visit for a condition seen
previously, or a periodic visit for a chronic condition as in the case of a house-bound patient.

If you are providing general coverage for routine services to a private care home, then you may
want to consider a contract directly with the facility. Pre-scheduled visits to the home every
Wednesday (as an example) and seeing all residents of the care home because the facility
requests that they be seen may result in a pattern of non-medically necessary services billed to
MSB. Per The Personal Care Home Act, residents of personal care homes can choose this
service option, do not have to demonstrate need to be admitted or follow any formal
placement process in order to reside there; therefore, there would not be a demonstrated
medical need for all residents to be seen on a regularly scheduled weekly/monthly routine
basis by a physician.

In contrast, per The Facilities Designation Regulations, special care homes are facilities
providing medical care to individuals that qualify for admission and have met the standardized
assessment criteria for placement as approved by the Ministry of Health.

October 1, 2021                                                                       Billing Bulletin

918A, 919A and 220A-226A – TIPS FOR SUBMITTING
In order for a claim to be processed for payment, the physician must provide the 3 criteria as
required by the Physician Payment Schedule.

For example, the 220A-226A requires:

1. The clinical condition necessitating continuous attendance, AND
2. Treatment or care provided, AND
3. Time when attendance on patient started and completed. The comment line may be used
   to provide this information. i.e. “Respiratory distress, CPR, airway stabilization, 0800-
   0930”.

        If the billing criteria is not met, the claim will be rejected with explanatory code “DR”

To avoid delays in processing, please provide the appropriate comment with submission(s).

 SECTION H - ANESTHESIA

193H - ACUTE PAIN MANAGEMENT BILLED IN CONJUNCTION WITH 815A-
839A (SPECIAL CALL SURCHARGES)
Special call surcharges are for use when a physician is called from a location other than the
hospital to attend to a patient on an urgent/emergent basis to provide services not otherwise
pre-arranged or pre-planned and without prior expectation of attendance to provide those
services. Billing of a special call surcharge is inappropriate when billed in conjunction with
services provided with the expectation of attendance to provide services, such as on a
“weekend call” basis or when the acuity of the day results in a patient being seen after 5 pm.

It is expected that the service of daily supervision is not being provided on an urgent or
emergent basis to attend the patient immediately.

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 SECTION J – SURGICAL ASSISTANCE

CLAIMS REJECTED WITH EXPLANATORY CODE JA OR JE
The Medical Services Branch only covers services that are medically required. If your claim is
rejected with explanatory code JA or JE, provide an explanation of the exceptional
circumstance required for:

   a. an assistant for a service that does not usually require an assistant; or
   b. additional assistants for a case that normally requires just one assistant.

Once additional information is received, it will be reviewed by Ministry Officials to determine if
the surgical assistance was medically required and eligible for payment.